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Chapter 2The Pre-Travel Consultation

The Pre-Travel Consultation

Lin H. Chen, Natasha S. Hochberg, Alan J. Magill

The pre-travel consultation offers a dedicated time to prepare travelers for the health concerns that might arise during their trips. The objectives of the pre-travel consultation are to assess the traveler’s trip plans and determine potential health hazards; to educate the traveler regarding anticipated risks and methods for prevention; to provide immunizations for vaccine-preventable diseases and medications for prophylaxis, self-treatment, or both; and to educate and empower the traveler to manage his or her health during the trip through counseling and prevention messages.

QUALIFICATIONS FOR PROVIDING A PRE-TRAVEL CONSULTATION

Much evidence has accumulated relevant to travelers’ health and forms the basis of pre-travel advice. Providers of pre-travel consultations should possess a general knowledge of the evidence base, understand disease epidemiology as well as routes of transmission and preventive measures, and be able to discuss the risks clearly with travelers.

The outcome of a pre-travel consultation likely depends on the expertise and communication skills of the provider, as well as the health beliefs of the traveler. In-person counseling by trained staff can effectively deliver some messages, in particular with regard to malaria risk and prevention. Familiarity with the traveler’s destination, its culture, infrastructure, and disease patterns can assist the travel health advisor in providing targeted messages.

Various health care providers may be asked to provide pre-travel consultation, including primary care providers and specialists who see their patients regularly (such as transplant surgeons or oncologists). These clinicians are familiar with the traveler’s medical history but may not have detailed knowledge of travel medicine. Travel medicine specialists have in-depth knowledge regarding immunizations, risks associated with specific destinations, and the implications of traveling with underlying conditions. Therefore, a comprehensive consultation with a travel medicine expert is indicated for any traveler with a complicated health history, special risks, or exotic or complicated itineraries.

COMPONENTS OF A PRE-TRAVEL CONSULTATION

Effective pre-travel consultations require attention to the health background of the traveler and incorporate the itinerary, trip duration, travel purpose, and activities, all of which determine health risks (Table 2-01). Advice should be personalized, highlighting the likely exposures and also reminding the traveler of ubiquitous risks such as injury, foodborne and waterborne infections, respiratory tract infections, and bloodborne and sexually transmitted infections. Written information is essential to supplement the discussion and highlight key advice for travelers. Balancing the cautions with an appreciation of the positive aspects of the journey leads to a more meaningful pre-travel consultation. Attention to the cost of recommended interventions may be critical. Some travelers may not be able to afford all of the recommended immunizations and medications, a situation that requires prioritizing interventions. (See Perspectives: Prioritizing for the Resource-Limited Traveler later in this chapter.)

Countries and specific regions, including order of countries if >1 country

Rural or urban

Timing

Trip duration

Season of travel

Time to departure

Reason for travel

Tourism

Business

Visiting friends and relatives

Volunteer, missionary, or aid work

Research or education

Adventure

Pilgrimage

Adoption

Seeking health care(medical tourism)

Travel style

Independent travel or package tour

Propensity for "adventurous" eating

Traveler risk tolerance

General hygiene standards at destination

Modes of transportation

Accommodations (such as tourist or luxury hotel, guest house, hostel or budget hotel, dormitory, local home or host family, or tent)

Special activities

Disaster relief

Medical care (providing or receiving)

High altitude or climbing

Diving

Cruise ship

Rafting

Cycling

Extreme sports

Assess Individual Risk

Many elements merit consideration in assessing a traveler’s health risks (Table 2-01). Certain travelers may confront special risks. Recent hospitalization for serious problems may even lead the advisor to recommend delaying travel. Air travel is contraindicated for certain conditions, and the travel health provider and traveler should consult with the relevant health care providers most familiar with the underlying illnesses. Other traveler characteristics that are associated with specific risks include travelers who are visiting friends and relatives, long-term travelers, travelers with chronic illnesses, immunocompromised travelers, pregnant travelers, and travelers with small children. More comprehensive discussion on advising travelers with specific needs is available in Chapter 8.

In addition to recognizing the traveler’s characteristics, health background, and destination-specific risks, the exposures related to special activities also merit discussion. For example, river rafting could expose a traveler to schistosomiasis or leptospirosis, and spelunking in Central America could put the traveler at risk of histoplasmosis. Flying from lowlands to high-altitude areas and trekking or climbing in mountainous regions introduces the risk of altitude illness. Therefore, the provider should inquire about plans for specific activities.

Manage Risk

Immunizations are a crucial component of pre-travel consultations, and the risk assessment forms the basis of recommendations for travel vaccines. At the same time, the pre-travel consultation presents an opportunity to update routine vaccines (Table 2-02). In considering travel immunizations, the approach to address “aggregate travel” or cumulative risk over years of travel, rather than risk associated with a single trip, allows travelers to prepare for multiple trips. Travelers should receive a record of immunizations administered.

Another major focus of pre-travel consultations for many destinations is the prevention of malaria. Malaria continues to cause substantial morbidity and mortality in travelers. In 2011, the number of US malaria cases reported to CDC was the highest since 1971; therefore, pre-travel consultation must carefully assess travelers’ risk for malaria and recommend preventive measures. For travelers going to malaria-endemic countries, it is imperative to discuss malaria transmission, ways to reduce risk, and recommendations for chemoprophylaxis.

Travelers with underlying health conditions require attention to their health issues as they relate to the destination and activities. For example, a traveler with a history of cardiac disease should carry medical reports, including a recent electrocardiogram. Asthma may flare in a traveler visiting a polluted city or from physical exertion during a hike; planning for treatment in case of asthma exacerbation can be lifesaving. Travelers should be counseled on how they can find reputable medical facilities at their destination. Any allergies or serious medical conditions should be identified on a bracelet or a card to expedite medical care in emergency situations.

The pre-travel consultation also provides the ideal setting to review wellness strategies with travelers and to remind them of healthy practices during travel. Topics to be explored are numerous and could be organized into a checklist, placing priority on the most serious and frequently encountered issues (Table 2-03). General issues such as preventing injury and sunburn also deserve mention. Written information is essential to supplement the oral advice and enable travelers to review the abundant instructions from their clinic visits. Advice on self-treatable conditions may minimize the need for travelers to seek medical care while abroad and possibly lead to faster return to good health.

Self-Treatable Conditions

Despite providers’ best efforts, some travelers will become ill. Obtaining reliable and timely medical care during travel can be problematic in many destinations. As a result, prescribing certain medications in advance can empower the traveler to self-diagnose and treat common health problems. With some activities in remote settings, such as trekking, the only alternative to self-treatment would be no treatment. Pre-travel counseling may actually result in a more accurate self-diagnosis and treatment than relying on local medical care in some areas. In addition, the increasing awareness of substandard and counterfeit drugs in pharmacies in the developing world (as many as 50% of the drugs on the shelves) makes it more important for travelers to bring quality manufactured drugs with them from a reliable supplier in their own country (see Perspectives: Pharmaceutical Quality & Counterfeit Drugs later in this chapter).

Travel health providers need to recognize the conditions for which the traveler may be at risk and educate the traveler about the diagnosis and treatment of those particular conditions. The keys to successful self-treatment strategies are providing a simple disease or condition definition, providing a treatment, and educating the traveler about the expected outcome of treatment. Using travelers’ diarrhea as an example, a practitioner could provide the following advice:

The treatment is ciprofloxacin 500 mg, every 12 hours, for 1 day (2 doses).

The traveler should feel better within 6–24 hours.

If symptoms persist for 24–36 hours despite self-treatment, it may be necessary to seek medical attention.

To minimize the potential negative effects of a self-treatment strategy, the recommendations should follow a few key points:

Drugs recommended must be safe, well tolerated, and effective for use as self-treatment.

A drug’s toxicity or potential for harm, if used incorrectly or in an overdose situation, should be minimal.

Simple and clear directions are critical. Consider providing handouts describing how to use the drugs. Keeping the directions simple will increase the effectiveness of the strategy.

The following are some of the most common situations in which people would find self-treatment useful. The extent of self-treatment recommendations offered to the traveler should reflect the remoteness and difficulty of travel and the availability of reliable medical care at the particular destination. The recommended self-treatment options for each disease are provided in the designated section of the Yellow Book or discussed below.

Urinary tract infections: common among many women; carrying an antibiotic for empiric treatment may be valuable.

Vaginal yeast infections: self-treatment course of patient’s preferred antifungal medication can be prescribed for women who are prone to infections, sexually active, or who may be receiving antibiotics for other reasons (including doxycycline for malaria chemoprophylaxis).

In sum, travelers should be encouraged to carry a travel health kit with prescription and nonprescription medications. Typical medications include malaria chemoprophylaxis, self-management of travelers’ diarrhea, and prophylaxis or treatment for acute mountain sickness. If a traveler anticipates the need to treat motion sickness, jet lag, or severe allergic reactions, consider medications for self-management, such as motion sickness therapy, a sleep aid, and epinephrine. Prescribing multiple medications, particularly for travelers already taking medications, warrants a review for possible drug interactions. More detailed information for providers and travelers is given in Chapter 2, Travel Health Kits; Chapter 8, Travelers with Chronic Illnesses; and Chapter 8, Humanitarian Aid Workers.

Table 2-02. Vaccines to update or consider during pre-travel consultations

Routine Vaccines

Haemophilus influenzae type b

No report of travel-related infection, although organism is ubiquitous.

Hepatitis B

Recommended for travelers visiting countries where HBsAg prevalence is ≥2% as well as screening for chronic hepatitis B in people from countries with HBsAG prevalence ≥2% (see Map 3-4). Vaccination may be considered for all international travelers, regardless of destination, depending upon the traveler’s behavioral risk as determined by the provider and traveler.

Human papillomavirus (HPV)

No report of travel-acquired infection; however, sexual activity during travel may lead to HPV and other sexually transmitted infections.

Influenza

Outbreaks have occurred on cruise ships, and 2009 influenza A (H1N1) illustrated the rapidity of spread via travel. Novel influenza viruses such as avian influenza H5N1 and H7N9 can also be transmitted to travelers visiting areas with circulation of these viruses.

Measles, mumps, rubella

Infections are common in countries and communities that do not immunize children routinely, including Europe. Outbreaks have occurred in the United States as a result of infection in returning travelers.

Meningococcal

Outbreaks occur regularly in sub-Saharan Africa in the "meningitis belt" during the dry season, generally December through June. Outbreaks occurred with Hajj pilgrimage, and the Kingdom of Saudi Arabia requires the quadrivalent vaccine for pilgrims.

Pneumococcal

Organism is ubiquitous and causal relationship to travel is difficult to establish.

Polio

Unimmunized or underimmunized travelers can acquire poliovirus, as occurred in a case reported in association with a stay with a host family in a Latin American country that had been declared polio-free.

Rotavirus

Common in developing countries, although not a common cause of travelers’ diarrhea in adults. The vaccine is only recommended in young children.

Tetanus, diphtheria, pertussis

Rare cases of diphtheria have been attributed to travel. Pertussis has occurred in travelers, recently in adults whose immunity has waned.

Varicella

Infections are common in countries that do not immunize children routinely, as in most developing countries. Naturally occurring disease also occurs later in tropical countries.

Zoster

Travel (a form of stress) may trigger varicella zoster reactivation, but causal relationship is difficult to establish.

Travel Vaccines

Cholera (not available in the United States)

Cases in travelers have occurred recently in association with travel to the Dominican Republic and Haiti.

Hepatitis A

Prevaccination incidence was 3–20 cases/1,000 person-months of travel, but recent surveillance indicated a decline to 3–11 cases/100,000 person-months of travel. Prevalence patterns of hepatitis A virus infection may vary among regions within a country, and missing or obsolete data present a challenge. Serologic testing may be considered in travelers from highly endemic countries since they may already be immune. Some expert travel clinicians advise people traveling outside the United States to consider hepatitis A vaccination regardless of their country of destination.

Japanese encephalitis

Rare cases have occurred, estimated at <1 case/1 million travelers to endemic countries.

Rabies

Rabies preexposure immunization simplifies postexposure immunoprophylaxis, as immunoglobulin in particular may be difficult to obtain in many destinations.

Tickborne encephalitis (not available in the United States)

Cases have been identified in travelers with an estimated risk of 1/10,000 person-months in travelers. Endemic areas are expanding in Europe.

Typhoid

UK surveillance found the highest risk to be travel to India (6 cases/100,000 visits), Pakistan (9 cases/100,000 visits), and Bangladesh (21 cases/100,000 visits), although risk is substantial in many destinations.

Yellow fever

Risk occurs mainly in defined areas of sub-Saharan Africa and the Amazonian regions of South America. Some countries require proof of vaccination for entry. For travelers visiting multiple countries, order of travel may make a difference in the requirements.

Abbreviation: HBsAg, hepatitis B surface antigen.

Table 2-03. Major topics for discussion during pre-travel consultations

Immunizations

Review routine immunizations and those travel immunizations indicated for the specific itinerary.

Discuss utility of titers when records are unavailable or unreliable, particularly for measles, mumps, rubella.

Screen for chronic hepatitis B for people born in countries with HBsAg prevalence ≥2%.

International Society of Travel Medicine. Body of knowledge for the practice of travel medicine—2012. Atlanta: International Society of Travel Medicine; 2012 [cited 2014 Oct 1]. Available from: http://www.istm.org/bodyofknowledge.